Hatred of sounds: Misophonic disorder or just an underreported psychiatric symptom?
Programa de Ansiedade e Depressão, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Rio de Janiero, Brazil
Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne, Melbourne, AustraliaLeonardo F. Fontenelle, MD, PhD
Programa de Ansiedade e Depressão, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Instituto D’Or de Pesquisa e Ensino, Instituto de Saúde da Comunidade, Universidade Federal Fluminense, Rio de Janiero, Brazil
BACKGROUND: Misophonia, or selective sound sensitivity syndrome, is a preoccupation with or aversion to certain types of sounds that evokes feelings of irritability, disgust, or anger. Recently, it has been suggested that misophonia is a discrete clinical entity deserving of its own place in psychiatric diagnostic manuals. In this paper, we describe 3 patients whose misophonia could be attributed to different underlying primary psychiatric disorders.
METHODS: Case series report.
RESULTS: In these patients, we argue that misophonia is better described as a symptom of a) obsessive-compulsive disorder, b) generalized anxiety disorder, and c) schizotypal personality disorder.
CONCLUSIONS: The nosological status of misophonia remains a matter of debate. Patients who exhibit misophonia as a major complaint should be assessed for other conditions. Further studies on the prevalence, natural history, and additional features of misophonia are needed.
KEYWORDS: obsessive-compulsive disorder, psychopathology, otorhinolaryngologic diseases, hyperacusia, tinnitus
ANNALS OF CLINICAL PSYCHIATRY 2013;25(4):271-274
Misophonia, or selective sound sensitivity syndrome, is an underreported preoccupation with or aversion to certain types of sounds that evokes feelings of irritability, disgust, or anger. Together with hyperacusis, misophonia is described in otorhinolaryngological literature as decreased sound tolerance, and frequently accompanies tinnitus.1 Hyperacusis is distinguishable from misophonia for being generalized to all sounds and leading to startle reactions.2
Misophonia and hyperacusis can be linked and present in individuals with normal hearing or hearing loss.1 In a study featuring 91 patients with hearing loss, 57% were diagnosed with misophonia, and 29.7% with hyperacusis.3 From a pathophysiological point of view, it has been suggested that misophonia involves the development of a conditioned response and enhancement of functional associations between the auditory, limbic, and autonomic nervous systems.4
Schröder and colleagues5 have provided the most comprehensive psychiatric account of misophonia to date. They describe clinical features of 42 treatment-seeking patients with misophonia who contacted their clinic after reading notices placed on a Dutch, web-based, misophonia newsgroup and their hospital website. In their study, all the patients referred to sounds produced by humans as “triggering stimuli.” Sounds included eating (eg, lip smacking), breathing, and typing-related sounds. Sound-related aversion sometimes was accompanied by distaste for its associated visual stimulus, or to movements performed by the source (misokinesia).5
In Schröder and coworkers’ series, exposure to the misophonic stimulus provoked an immediate aversive physical reaction, starting with irritation or disgust and resulting in anger. Typically, individuals strived to avoid misophonic sounds (eg, by wearing headsets), experienced daily distress by anticipating misophonic stimuli, and described their loss of self-control as morally unacceptable. Neuroticism among these patients was reported as being higher than in the general population, with more than one-half of patients meeting criteria for obsessive-compulsive personality disorder.5
In lieu of misophonia symptomatology fitting into DSM-IV-TR or ICD-10 classifications, Schröder and colleagues suggested that misophonia should be considered a discrete clinical entity, 1 deserving of its own place in future diagnostic systems.5 In this paper, we provide detailed accounts of 3 patients whose misophonia could be the result of different underlying primary conditions.
Mr. A, age 25, is an unemployed, single man who was referred to our obsessive-compulsive disorder (OCD) clinic by his attending psychiatrist. Mr. A’s psychiatrist was concerned about his patient’s lack of response to treatment with serotonin reuptake inhibitors (SRIs). Since age 10, Mr. A has described bothersome feelings brought on by certain environmental “sounds,” such as people coughing, dogs barking, and birds singing. He lives alone in a small house located in a poor area on the outskirts of Rio de Janeiro. These annoying sounds lead Mr. A to freeze and perform repetitive actions, such as stroking objects, touching his teeth, and coughing or contracting his abdomen, as if expelling “something bad.”
Believing that a “terrible event” would happen if he did not perform his compulsive actions, Mr. A described feeling extreme guilt if he attempted to ignore or was unable to execute these compulsions. His symptoms interfered with normal functioning. For example, they would prevent his movement from 1 room to another, because he would have to freeze and re-evaluate the sequence of events that led to that particular moment. Mr. A also reported being unable to leave home, because his movements would cause the neighbor’s dogs to bark, leaving him stranded at the front door. He was diagnosed with OCD. Unfortunately, despite being prescribed a combination of different SRIs and antipsychotics, Mr. A did not respond to treatment.
Mrs. B, age 41 and a secretary, sought treatment because she believed she had OCD. She was annoyed by different sounds, such as those produced by throat clearing, gum chewing, forks and knives, clinking glasses, candy wrappers, and keyboards. This aversion led her to avoid social situations, such as eating with her family, going to the cinema, or spending time with people in closed environments. Mrs. B was particularly bothered by domestic noises, and described being irritated by them since age 17. However, her irritability was not restricted to these themes.
Witnessing other people’s routines, which distracted her and interfered with her ability to read or watch TV, also distressed her. Mrs. B was persistently preoccupied with daily events, an inability to relax, headaches, insomnia, difficulty concentrating, onychophagia, and other diffuse somatic complaints. Nevertheless, she denied typical OCD symptoms, and was diagnosed with generalized anxiety disorder (GAD). As a child, Mrs. B reported being raised in strict environment and being punished by her father for putting her hands on the table during dinner. As punishment, he would force her to “stand for 1 hour in silence.” After more than 6 months on fluoxetine, 60 mg/d, she reported partial improvement (40% reduction) of her symptoms, including of the distress generated by sounds.
Mr. C, age 55, was a married, retired engineer referred to us by his attending psychiatrist, who believed Mr. C had OCD. Since age 30, Mr. C reported being increasingly annoyed by and preoccupied with sounds his neighbors made, including footsteps, conversations, laughter, vacuum cleaners, and furniture being moved around. Family members confirmed the existence of noisy neighbors, but also stated that Mr. C pays too much attention to them. Mr. C had a history of social isolation and alcohol abuse. His aversion led to him spending most of each day outside of his house, wandering the streets and drinking in pubs. He constantly anticipated the distress associated with these sounds, and complained about them to his wife and mother.
He was reluctant to complain directly to his neighbors, fearing their reactions and stating, “They could make even more noises.” He also was concerned that security cameras strategically placed in his building have already captured footage of him complaining to his neighbors. He reported that these sounds often led to him to contemplate suicide, but no other consistent depressive or obsessive-compulsive symptoms were noted. He was diagnosed with schizotypal personality disorder and alcohol abuse. Mr. C received olanzapine, 20 mg/d, fluvoxamine, 200 mg/d, and maintenance electroconvulsive therapy. With his mother’s help, Mr. C plans to buy an apartment without neighbors nearby to avoid distressing sounds. During examination, he displayed a flat affect and was ambivalent regarding his neighbors. Although he recognized that his irritability was at times exaggerated, he believed that they occasionally made noises deliberately to annoy him.
We have described 3 patients who sought treatment for misophonia at our OCD clinic. Although 1 of these patients was self-referred, attending psychiatrists of the other 2 patients sought our consultation. The self-referred patient was diagnosed with GAD, while the remaining 2 patients were diagnosed with OCD and schizotypal personality disorder, respectively. These findings suggest that patients and clinicians may perceive misophonic complaints as sharing common features with OCD. This perception accords with Schröder and coworkers’ proposal, which advocates for misophonia being considered an OCD spectrum condition.5 However, as illustrated in 2 of the 3 cases reported here, associations with obsessive-compulsive symptoms also may be minimally evident.
In these 3 cases, misophonia could be recognized as a symptom of other psychiatric disorders, namely OCD, GAD, or schizotypal personality disorder. In our first case, distressing sounds were followed by typical compulsive behaviors. A related misophonic phenomenon, “being bothered by certain sounds/noises,” is included in conventional assessments of OCD symptomatology under the category of “miscellaneous” obsessions.6,7 Misophonia also may be conceptualized as a form of “sensory phenomena” that occurs in OCD and tic disorders as uncomfortable and distressing subjective experiences that precede or accompany repetitive behaviors.8 In Tourette syndrome, misophonia has been reported as a secondary phenomenon.9
We also described a patient whose misophonia could be functionally ascribed to pervasive irritability, which is recognized as a key feature as well as a core symptom of GAD.10 We speculate that irritable patients may be especially prone to reporting misophonic complaints. Notably, in one follow-up study, irritability at age 14 was found to predict GAD, major depressive disorder, and dysthymia 20 years later.11 Schröder and colleagues also raise the issue of differential diagnoses between misophonia and other conditions characterized by irritability and impulsive aggression (eg, intermittent explosive disorder, and cluster B personality disorders), suggesting that aggressive outbursts of rage are much less frequent in misophonic disorder than in these conditions.5
One of our patients’ misophonic complaints displayed self-referential features. He was ambivalent about the “noises” his neighbors made although he recognized that his irritability was out of proportion; occasionally felt that his neighbors made the sounds deliberately; and was afraid that reacting would make things worse. He was socially isolated and displayed a flat affect. It is difficult to categorize this patient’s misophonic symptom, but we believe it could be accommodated by the concept of “delusional interpretation,” or “a false reasoning which takes as its starting point a real sensation, a correct fact, which through associations of ideas linked to tendencies, to affectivity, and through mistaken inductions or deductions, takes on a personal meaning.”12 Delusional interpretations originally were described in individuals with disordered personalities, particularly paranoid personality disorder.12
Misophonia should be differentiated from other conditions, such as tinnitus and hyperacusia.13 Unfortunately, because we did not perform audiologic assessments of our patients, it is unclear whether they merit additional diagnoses.
In summary, the nosological status of misophonia in psychiatry remains a matter of debate. Our findings suggest that patients who exhibit misophonia as a major complaint should be assessed for other psychiatric disorders before making a diagnosis of primary misophonic disorder.9 Further research on the prevalence, natural history, and additional features of misophonia are needed to resolve the ongoing debate.
DISCLOSURES: Dr. Ferreira reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Harrison is supported by a National Health and Medical Research Council of Australia (NHMRC) Clinical Career Development Fellowship (ID 628509). Dr. Fontenelle receives grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico (# 303846/2008-9), Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (E-26/103.252/2011) and Instituto D’Or de Pesquisa e Ensino and is a member of the WHO ICD Revision Working Group on the Classification of Obsessive-Compulsive Related Disorders, reporting to the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. The views expressed in this article are those of the authors and, except as specifically noted, do not represent the official policies or positions of the International Advisory Group, the Working Group on Obsessive-Compulsive Related Disorders, or the WHO.
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CORRESPONDENCE: Leonardo F. Fontenelle, MD, PhD Anxiety and Depression Research Program Institute of Psychiatry of the Federal University of Rio de Janeiro Rua Visconde de Pirajá, 547, 719 Ipanema, Rio de Janeiro-RJ, Brazil 22410-003 E-MAIL: firstname.lastname@example.org
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